Provider Demographics
NPI:1265552160
Name:RUSSELL, JENNIFER ANN (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1038
Mailing Address - Country:US
Mailing Address - Phone:317-726-0136
Mailing Address - Fax:
Practice Address - Street 1:13752 LAKERIDGE DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7608
Practice Address - Country:US
Practice Address - Phone:317-576-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010066A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics